A conundrum: general or neuraxial anesthesia and the use of ROTEM.

We report the use of rotational thromboelastometry (ROTEM) to guide the management of a 29-year-old primigravida at 36weeks' gestation with portal hypertension, esophageal varices, suspected pseudocholinesterase deficiency, and steroid refractory thrombocytopenia presenting to labor and delivery with worsening peripheral edema and new-onset hypertension. A multidisciplinary decision for preoperative platelet transfusion and cesarean delivery under spinal anesthesia was made, guided by ROTEM. A successful cesarean delivery was performed with no bleeding complications.